Premera Blue Cross



Member International Claim Form

for Amazon and Subsidiaries

This form is to be used for medical charges incurred outside of the United States.

Please note: Your claim will be returned if all of the information required below is not included.

See instructions on the next page for additional information to complete your claim. Premera Blue Cross will not pay a bill submitted more than 12 months after the date of service.

|1. Patient / Member NOTE: Complete a separate claim form for each patient/member. |

|Premera Blue Cross Identification # |Group number |Prefix |Patient name (first, middle, last) |Relationship to subscriber |

|      | | |      |      |

|Subscriber name (first, middle, last) |Patient date of birth (month/day/year) |Home phone number |

|      |      |      |

|Address |City |State |ZIP |

|      |      |   |      |

|Does the patient have coverage from any other health plan? |

|No, skip to section 2 Yes, please attach the Explanation of Benefits (EOB) statement from the primary plan with this claim, and complete the following |

|information. |

|Name of other health coverage plan |ID number or policy number of other health plan |Phone number of other health plan |

|      |      |      |

|2. International Claim Details NOTE: You must submit an itemized bill or your claim will be returned. To expedite processing please provide translation and |

|include proof of payment or point of sale receipt. Provide available medical records and complete this section. |

|In what setting were these services performed? |

|Inpatient hospital – Date of Admission:       Date of Discharge:       |

|Outpatient hospital Office/clinic Surgery center Skilled nursing center Home/lodging Other:       |

|Name and complete address of servicing provider |Country of service |Type of provider |Date of service or purchase |

|      |      |Hospital Lab |      |

| | |Physician/Office X-ray | |

|What was the reason for obtaining medical treatment outside of the United States? |Billed charges |Amount paid |Foreign currency type |

|      |      |      |      |

|Detailed description of illness and symptoms requiring treatment |

|      |

|Detailed description of service and/or item purchased (per itemized charge). NOTE: Add additional sheet if necessary. |

|      |

|3. Accident / Injury |

|Is this claim due to an accidental injury? |Date of accident |Where did the accident occur? |

|No, skip to section 4 Yes, complete this section |      |Home Work School Auto Other:       |

|How did the accident happen? |

|      |

|Description of injury |

|      |

|4. Signature |

|To be accepted, this form must be fully completed (as appropriate to the claim being submitted), signed, and have itemized bill attached. |

|Mail to: Premera Blue Cross, P.O. Box 91059, Seattle, WA 98111-9159 |

|Please note: It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. |

|Penalties include imprisonment, fines, and denial of insurance benefits. |

|Patient signature (or legal guardian if patient cannot legally consent to services) |Relationship to patient |Date (month/day/year) |

| |Self |      |

| |Other:       | |

Instructions

A. Complete a claim form and attach the itemized bill. Please do not highlight or modify the itemized bill as this may cause delayed processing of your claim. To expedite processing please provide translation and include proof of payment or

point of sale receipt.

The itemized bill must contain all of the following information:

• Name of the member who incurred the expense.

• Name and address of the servicing provider and/or facility.

• Detailed description of illness and symptoms and/or diagnosis code. This information must be obtained from your provider.

• Detailed description of services and/or procedure codes and/or items purchased. This information must be obtained from

your provider.

• Date of service and itemized charge for each service rendered and/or items purchased.

Please note: Your claim will be returned if all information required above is not included.

B. If you have other coverage, attach a copy of the bills you submitted to the other plan and an Explanation of Benefits (EOB) you received from the other plan.

C. The front of your member ID card may not match the card pictured below. This sample card is meant to be a guide to help you identify your prefix, identification, and group numbers. These numbers are required to complete your claims form.

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1 — Prefix and Identification # help us verify your eligibility,

determine your coverage and process claims.

2 — Group # identifies your plan’s benefits.

D. Send the completed claim form and bills to:

Premera Blue Cross Customer Service: 1-877-995-2696

P.O. Box 91059 Fax: 1-800-676-1477

Seattle, WA 98111-9159

*Register online at Amazon to submit claims electronically through your member portal.

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P.O. Box 91059

Seattle, WA 98111-9159

P.O. Box 91059

Seattle, WA 98111-9159

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